Security and Crises
From the time that it was opened as the Criminal Insane Building in 1933, the forensic division in Penetanguishene was designated as a maximum-security mental health facility. As such, both the daily routine and the physical building were subject to security considerations and restrictions that distinguished the division from the regional division of the hospital as well as other mental health care centres in the province.
The Folger Adams System
One of the most immediately distinctive features of the Oak Ridge building was its heavy grilled gates and oversized steel keys.
Oak Ridge employed the Folger Adams detention locking system for most of its history (Southern Folger, 2015). The system is common to correctional facilities and is easily recognizable by its large, distinctive keys that feature an "A" in their design. These keys were used to open the gates in the front and freight entries, the ward and sunroom entrances, and various hallway or common room spaces. The process for unlocking and opening each gate was carefully regulated: the entry, for instance, operated on a two gate system whereby a person entering the building from outside - staff, patients, and visitors alike - would wait in the entry for the exterior gate to be locked before the second gate that allowed them into the building itself was unlocked.
Patient room doors operated on a similar system which allowed for the locking or unlocking of all doors at the same time or individual doors, depending on the need. A crank system located at the entry to each ward controlled this mechanism.
Alarm buttons were installed at various strategic points within the building from its opening. In the original arrangement, buttons were placed on the wall of the hydrotherapy room at the end of each ward so that Attendants could signal for assistance if needed.
In later years, the buttons - which became known as "Code White Buttons" - were placed on walls throughout the facility. If they were in need of assistance, an Attendant or other staff member would press one of these buttons which would then send a signal to the front office. That office would then make an announcement over the P.A. system to alert other staff members to the situation.
There was also an exterior siren installed at the building in 1938 in response to a series of escapes during the earliest years. The siren was intended to use as a warning signal for the Hospital as well as the surrounding community upon the escape of a patient or if there were some sort of internal trouble within the building. It is unclear from the records when this siren was removed but it was not in operation during the final decades of the division's history.
The Oak Ridge building was under nearly continuous observation throughout its history. The long narrow ward hallways allowed Attendants to observe any activity taking place outside the 38 individual rooms, even at a distance. Open grating on individual patient room doors also allowed for Attendants to see directly into every room as they walked by.
In later years, video cameras were installed throughout the building and a live feed was monitored 24-hours a day in the front office. This office was likewise responsible for monitoring, relaying, and directing the security codes from the regional division of the hospital.
Preparing for the Worst
Attendants and staff of Oak Ridge trained for the worst case scenario. As a result, security and protection devices were installed throughout the building. Over the decades these ranged from gas guns on each ward in the late 1930s to personal riot gear and protection shields stored in wall-mounted boxes in the 1990s-2000s. Other variations included common items such as a pair of scissors located inside the Folger Adams box at each ward entry to be used in case of attempted suicide by hanging.
Security Rules and Policies
Over the course of its history, Oak Ridge developed an extensive and detailed set of regulations - later, policies - that governed all aspects of daily life within the division. While these overlapped extensively with the administration of treatment as well as the general routine of the division, the focus was on maintaining security and preventing or quelling violence.
Regulations for the New Building
A standard set of regulations were issued the month prior to the opening of the Criminal Insane division in 1933. The details primarily described the physical layout of the building. For both Attendant staff and patients it listed the Attendant duty and patient room opening/closing hours as well as their respective meal schedules. This regulations document also specified the expectations concerning the keeping of record books for all ward, treatment, and occupational/outside work.
In terms of actual security concerns, the initial written regulations focused only on the process for the keys used at the building and the daily count of patients. No additional discussion for how to handle disruptive or violent patients was listed.
A Policy for Every Possibility
As the years progressed, the policy manual governing life inside Oak Ridge grew exponentially from the initial four page document issued in 1933. By the early 1980s, the Oak Ridge Front Office Procedures Manual and General Information had grown to fill a binder. The expanding scope of the manual included both the broad philosophy governing the policy decisions made within Oak Ridge as well as detailed procedures: the admission and discharge of patients; daily activities within the building; room-by-room security policies; and detailed procedures on how to handle a wide range of potential threats that could occur - riots, hostage-takings, and violent attacks.
The manual included detailed examples of varying situations that could arise within Oak Ridge and how they were expected to be handled. These details ranged from how staff should exchange keys, pass through gates, and monitor the permimeter of the building to the process for controlling the ward environments, the use of pharmacological controls, and the process for detaining a patient who acted in a violent or aggressive manner.
The security manual likewise included more general day-to-day policies such as the process for shaving patient beards or the cutting of their hair, permitted personal items, restrictions on gambling behaviours, and so on.
Security through Secrecy
Perhaps the most distinctive feature of Oak Ridge's security history was its secretiveness. In order to preserve a strict level of security, the official policies and procedures of the Oak Ridge division were kept closely guarded from all outsiders - even fellow employees at the regional division were kept in the dark regarding many of these details.
Not all policy documents were subject to information blackouts - descriptions of staff responsibilities, visitor policies, and other operational details were openly shared. However, those procedures which were more security-focused - such as the actions taken during the occurrence of a behavioural situation, in the case of a missing patient, during security checks, or the general yard policies - were heavily redacted if the copy of that document was stored outside of the Oak Ridge building.
During the later half of Oak Ridge's history, patients, staff, and visitors to Oak Ridge were subject to a host of detailed rules and restrictions in order to maintain a secure environment. The expansion of the Procedures Manual over the years specified many of these details - but there remained some policies which were never officially recorded.
For example, with few exceptions (the STU programming of the 1960s-early 1980s being one) patients were not permitted to have a second patient present in their personal room. This was in part to protect against potential conspiratorial plotting or violence but also to discourage acts of a sexual nature. Another example governed the movement of patients: on the ward hallways signs were posted indicating how close a patient could come to the nursing station without first requesting permission. Similarly, the sunrooms and recreational spaces featured restrictions on the rearrangment of the furnishings in an effort to prevent the items from being used as weapons or blockades.
Escapes & Escape Attempts
Over the course of its 81-year history, there were only a handful of successful escapes from Oak Ridge - most of these in its first decade. A highly-controlled regimen, prison-like structure, and continuous monitoring by staff help to explain why. In recognition of an impenetrable reputation, it has at times been known as the "Alcatraz of Canada" (Boyd, 1963; Caron, 1978).
Flaws in the Structure
In the months leading up to the arrival of the first patients in 1933, the local Midland Free Press newspaper told its readers that the new building at the Ontario Hospital, Penetanguishene was designed such that there was "no possibility left to escape." (Ontario Hospital addition is fine modern structure, 1932). The statement would soon prove premature.
While there was but a single successful escape in the division's first year of operation - and that by a man who returned of his own accord the following day - there were multiple attempts made by other patients. The most extensive of these plans involved a group of patients who were caught hiding hacksaw blades in their mattresses which they had intended to use to cut through the window bars.
A handful of successful escapes occurred annually before the number spiked to six in 1935. By the time another two patients found their way off the grounds in early 1936, an inquest was held. Blame was laid on the brand new building itself. The fence surrounding the yard was considered particularly inadequate with staff and patients testifying that it was well-known to be an easy climb.
The height of the barbed wire that ran along the top and the fence and the angle of the bars were immediately altered. But this, too, was considered insufficient and before it its fourth year of operation, the fence of the "New Building" was rebuilt in its entirety and screen guards were added to the windows of the upper floors for extra security.
Cookies, Cakes, and an Accomplice on the Outside
The building modifications made in the early years quelled the number of escapes. By mid-century, a new ruse was used: the accomplice on the outside.
There were only three successful escapes between 1954 and 1979. In the first case, a patient's girlfriend used a batch of cookies to smuggle a hacksaw blade into Oak Ridge during visiting hours. Three patients later used the blade to saw through the window bars - two were able to squeeze through the small space and secure their escape. Another patient escaped Oak Ridge following a visit by his brother. At the conclusion of his visit, the patient's brother produced two handguns and escorted the patient off the property.
Although unsuccessful, perhaps the most famous escape attempt of this period took place in 1960. Around the Christmas holidays, a large package arrived addressed to an Oak Ridge patient. It was colourfully wrapped in printed paper, tied with twine, and clearly marked "CONTENTS - FOOD." A box filled with treats was not an unusual sight among the regular mail received at the division, especially over the holidays, but something stood out about this particular box. Florida Bald, who was sorting the mail that day, brought it to the attention of the Assistant Superintendent, Dr. Kenneth McKnight.
The required contents list specified a standard mix of sugary sweets: marshmallows, chocolate bars, gummy bears, and Christmas cake - all in the original store-bought packaging. Just to be sure, the decision was made to x-ray the package:
"Sure enough, someone had hollowed out the cake and put a gun inside" (Bald, as quoted in "The old gun in the cake trick," 1989).
Dissection of the cake revealed a handgun, bullets, and tear gas shells. The package was photographed and sent to a crime lab in Toronto for follow-up. Charges were later laid against the intended recipient for conspiring to escape lawful custody. The incident also led to the policy that all patient mail was to be scanned before it was delivered.
Opinions "On Rats"
Following an escape attempt by two patients in August of 1965, one Oak Ridge patient published an editorial on the event in the patient-published newsletter The Quill. The account was later republished in a local newspaper, the County Herald.
In this article, entitled "On Rats," the author criticized the fact that the men in question had been able to act on a plan to escape without any other patients reporting knowledge of the plan to Attendants. He blamed the prison-like mentality of the division where patients failed to report what they knew for fear of being labelled as snitches or rats. He also raised concerns about how a few bad grapes could spoil the bunch for everyone:
"As always, the semi-innocent majority might have had to bear the consequences of the act of a couple of upset men."
"Oh, we don't mean that you should trot along to Mr. Blad every time X fails to change his socks, or that you should set yourself up at the Judge of your neighbor's morality in small matters. We just mean it is foolish to subscribe to the pensubculture with its stool pigeons, rats and rounders. It is downright silly to think in terms of Us versus Them come what may" ("Patient expresses view of Oak Ridge escape attempt," 1965).
In addition to a rash of escapes, the earliest decade of Oak Ridge's history was defined by a series of suicides and suicide attempts by the new patient population. Depression was found to be high among the new arrivals and four patients hanged themselves within a short time of one another - with a handful of others making similar attempts on their lives.
The Director of Hospital Services for the province, B. T. McGhie, ordered an investigation; the results of which identified serious concerns about the design of the building. Immediate changes undertaken included lowering the height of the radiators in patient rooms, removing hinged brackets and padlocks from the wards, and the construction of a new observational dormitory for those patients deemed to be at highest risk of suicide. Efforts were also made to attend more closely to the general comforts offered to patients, including returning to the brand of tobacco they had previously been accustomed to.
While the alterations to the building helped to minimize the number of suicide attempts throughout the remaining history of the division, it could not eliminate them entirely.
Working or living at Oak Ridge did involve a daily risk of violence. Violence could stem from patient-to-patient acts, patient-to-staff, or staff-to-patient. The rules and policies implemented throughout the history of the division were intended to curtail such acts, but the risk remained.
Employment at the Oak Ridge division meant facing a the possibility of violence on any given day. As one Attendant put it:
"It is a dangerous job. Some people exaggerate the danger and others really underplay it" (Tina Bricker, as quoted in "Life as an Oak Ridge attendant," 1990, p. 10)
In 1977, for example, 198 assaults were committed by patients with 66% of the victims being staff. In 1979, 511 working days were lost due to injuries caused by patient assaults. Over the years, some staff were hit, bit, stabbed, and sexually assaulted.
In direct response to the risks, a crisis prevention and intervention training course was first implemented at Oak Ridge in 1981. The course was developed by Oak Ridge researchers, led by Drs. Marnie Rice and Vern Quinsey, and involved role-playing specific scenarios to help break down how to diffuse an aggressive situation. It emphasized how to get patients to express their feelings so that the situation could be de-escalated quickly.
In the early 1990s, a group of former Oak Ridge patients along with the Ontario Psychiatric Survivors Association alleged that several patient suicides that had occurred during the 1960s and 1970s had, in fact, been murders committed by Attendants. They also alleged physical and sexual abuses during this period. The accusations created much media attention and the Ontario Provincial Police (OPP) was called in to investigate.
The investigation involved 10 deaths and 37 other incidents that were investigated over a period of nearly nine months. Newspapers published accounts of former patients who had witnessed or experienced these acts and described acts such as "choking out." Representatives from the Ontario Psychiatric Survivors Association explained this as a method of rendering a person unconscious:
"This, they say, was done by wrapping a towel around their necks for several seconds, blocking the flow of blood from the brain to the heart" ("The man who wasn't there," 1992).
The group staged a protest infront of the Provincial Legislature in Toronto in March of 1992, holding signs that included statements such as "Stop the torture, stop the pain" ("Former Oak Ridge patients take demands to Queen's Park," 1992).
The Hospital and OPSEU, the union that represented Oak Ridge Attendants, denied the claims throughout the investigation. Both parties further cited the continued coverage in the media as "demoralizing" ("Special investigation at Oak Ridge widens," 1992).
In June of 1992, the OPP closed its investigation. They reported that the accusations were unfounded.
Over the course of its history, Oak Ridge employed mechanical (ex. handcuffs) and environmental (ex. seclusion rooms) restraints. With the changes in the Attendant role and security requirements that came as a result of the advent of psychopharmaceuticals in the 1950s and 1960s, the regularity with which these processes were resorted to decreased dramatically. For example, in 1970 it was estimated that the number of patients in solitary confinement at any one time had dropped from 50% to just 5% during this period.
By Jennifer L. Bazar
Page Last Updated: June 4, 2015
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How to Cite this Page
Bazar, J. L. (2015). Security and crises. In J. L. Bazar (Ed.), Remembering Oak Ridge Digital Archive and Exhibit. Retrieved from https://historyexhibit.waypointcentre.ca/exhibits/show/dailylife/security-crises